Provider Demographics
NPI:1992707871
Name:REDMOND, MICHAEL DAVID (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:REDMOND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:223 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-8049
Practice Address - Country:US
Practice Address - Phone:803-296-2414
Practice Address - Fax:803-296-2400
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14236208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC564OtherBCBS SUFFIX GROUP
SC142367Medicaid
SCE12480Medicare UPIN
SCAA27965742Medicare PIN
SC200028300Medicare ID - Type Unspecified
SC142367Medicaid